Acute Limb ischemia in elderly

[Ben Reynolds]

Saad:

Sad outcome.  

I suspect that her aorta didn't rupture, though no one can be 100 percent certain in the absence of a postmortem.  If she complained of back pain prior to her demise it was, in all likelihood due to retrograde dissection of blood into her retroperitoneum from the CFA bleeding and not from a ruptured aneurysm; which isn't to say that's not what happened just that given this sort of instrumentation other causes are more likely.  

Alternatively, if she were afferently catheterized from the contralateral CFA (right to left over the aortic bifurcation)  that has a tendency in my observations to predispose a higher rate of mechanical vascular injury (aorto-illio-femoral dissection with rupture, wire perforation of an aortic plaque, etc).

As to your questions:

1.  Could this pt develop severe DIC with clot to Right (intact) leg vs. clott triggered by the sheath.

Sure.  But probably is more likely due to the latter and many other factors which can't be 100% controlled for.

2.  if we suspect AAA rupture, is there any role for US at bed side, if not and pt is unstable at this point, is DPL going to help

Ultrasound at the bedside for most of us is only good answering whether or not there is fluid within the peritoneal cavity which would be helpful with free intraperitoneal rupture.  If it's contained within the retroperitoneum then no.  Same for DPL.  Seeing the abdominal aorta on ultrasound is no help as you know the aneurysm already exists.  I'm sure a radiologist at the bedside with a diagnostic quality ultrasound machine could give you more information (clot in the retroperitoneum and the sort) which will never happen in a real world situation. 

Let's assume for a moment that her aneurysm IS ruptured, who would have pursued fixing it given her overall medical status, even emergently?

3.  could the tPA quickly accelerate her AAA rupture.

Only if her aneurysm had already ruptured and was contained.  If that were the case she would have been dead less than an hour after tPA was initially started, certainly not the next day.

4.  anything to be done differently in this patient.

In my humble opinion, no.

Ben Reynolds, PA-C
Pittsburgh, PA



----- Original Message ----
From: saad shebrain <shebrain1 at yahoo.com>
To: trauma-list at trauma.org
Sent: Sunday, December 2, 2007 1:43:20 PM
Subject: Re: Acute Limb ischemia in elderly

Than you all,
  All options you give are more than reasonable.
  
  Now, discussion with family and pt they preferred to proceed with throbolytics with risk of bleeding.
  
  Angio done, Complete Graft occlusion, with some collaterals for the profunda.
  tPA started, overnight, Fibrinogen drop to 118, 68, tPA was D/Cd per IR at 2 AM, although some said you could decrease the dose to quarter/h, in AM H/H 12/35, fibrinogen 60.
  6AM pt lost the pulse in Rt DP,PT.
  
  Pt was taken to IR, the graft Still completely occluded. MECHANICAL thrombectomy cleared the clot, and flow distally to ankle (PT was achived), on the Rt leg, the Pop at trifurcation is out.
  
  Decision was stop and take sheth out and start heparin drip once pt returned to ICU.
  in IR suite, BP was 110-140/50-70s, HR 110-140s A-fib
  
  Rt groin hematoma was noticed after removing the sheath, 30 min pressure applied.
  
  In ICU hematoma was larger, and H/H wa 6/18, pH 6.98, pt desat, intubated, became hypotensive, multiple CPRs and drugs. she was transfused and prepared for a trip to OR for groin X-ploration. she required 2 pressors
  ECHO; 30% EF, severe MR.
  
  abdomen was distended.
  
  in OR, the puncture in her CFA, was not enogh to explain her drop in H/H. apprx. 500 ml blood in the thigh. no concern about significan retroperitoneal bleeding from the CFA puncture site.
  
  on return to ICU pt developed bradycardia and cardiac arrest.
  
  Q:
  1. Could this pt develop severe DIC with clot to Right (intact) leg vs. clott triggered by the sheath.
  2. if we suspect AAA rupture, is there any role for US at bed side, if not and pt is unstable at this point, is DPL going to help.
  3. could the tPA quickly accelerate her AAA rupture.
  4. anything to be done differently in this patient.
  
  Thankx
  
  SS
  
  




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